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Background: Antimicrobial resistance (AMR) is a global public health concern that has the potential to reverse decades of progress aimed at decreasing morbidity and mortality attributed to infectious diseases. In 2019, ~5 million deaths were associated with AMR, of which 1.2 million were attributed to antibacterial-resistant infections. Healthcare facilities where antimicrobials are frequently used are high-risk settings for the selection and spread of resistant bacteria, and they further contribute to the increase in the burden of AMR. We have documented the prevalence and indication of antibiotic use in a tertiary-care referral hospital in Freetown, Sierra Leone. Methods: This point-prevalence survey was conducted at Connaught hospital, a tertiary-care hospital in Sierra Leone, in November 2021. The hospital offers a range of medical and surgical services through 25 units and has 16 wards with >300 beds. Data on patient-level antibiotic use, including indications for use, were extracted from medical records using WHO point-prevalence survey (PPS) forms that had been pretested and validated. Data collection was conducted in all the wards over a 10-day period by trained healthcare personnel. On the day of the survey, only the medical records of patients on admission before 8:00 a.m. on that day were included in the study. Data entry, cleaning, and analysis were conducted using the WHO PPS platform. Ethical approval was obtained. Results: In total, 87 patient records were included in the survey. Most (71%) were women, and the average age was 30.6 years. The prevalence of antibiotic use was 66%, and the average number of antibiotics prescribed to patients since admission was 2. The 5 most prescribed antibiotics were metronidazole, ceftriaxone, amoxicillin and clavulanic acid, ampicillin and cloxacillin, and azithromycin. The parenteral route of drug administration was the mainstay. The most frequent indications for antibiotic prescription were community-acquired infection and surgical prophylaxis. Blood-culture requests were not ordered before the initiation of antibiotic treatment. Conclusions: This study was the first study to be conducted in Connaught hospital using the WHO PPS methodology. The survey reports a high prevalence (60%) of antibiotic use, and most treatment was done empirically. This finding is contrary to the WHO recommendation of

Background: Infection prevention and control (IPC) is a clinical and public health discipline based on a scientific approach and practical preventive and control measures. During the 2014–2016 West African Ebola outbreak, the high number of healthcare worker infections was attributed to inadequate IPC in Sierra Leone. This stimulated the establishment of national and subnational IPC programs. Since then, IPC has remained a priority to improve the health systems and strategic interventions during public health emergencies. Therefore, we conducted a detailed review to assess the status of the IPC programs. Methods: A descriptive analysis of the status of IPC programs in Sierra Leone was done using data from IPC assessments conducted in 2022 by the national IPC team, reviews of reports on program implementation, and experts’ objective opinions. Results: Performance. The national IPC assessment revealed strengths in 4 of 6 WHO IPC core components, with an overall score of 61% positioned at the ‘intermediate’ level of implementation. The best-performing component was ‘IPC guidelines’ (92%) with evidenced-based guidelines being developed and implemented over the years. Secondly, ‘Education and training’ (71%) made progress in basic and advanced IPC training, including the development of a preservice training curriculum. Also, ‘monitoring and audit and feedback’ (69%) and ‘IPC program’ (61%) met the basic requirements of an established Monitoring & Evaluation (M&E) system. Similar progress was made at the healthcare facility level, but with major gaps in ‘workload, staffing, bed-occupancy’ and ‘safe or built environment.’ Sustainability efforts. Evidence-based data on IPC have always been scarce due to a limited capacity to conduct IPC research. The Structured Operational Research and Training Initiative (SORT-IT) on antimicrobial resistance has helped promote evidence-informed decisions and build OR capacity that is relevant to improving program performance. In 2019, Sierra Leone instituted in-country production of alcohol-based handrub and liquid soap as a strategic intervention for providing hand hygiene products for use in healthcare facilities. This intervention was essential during the peak of the COVID-19 pandemic. Although most aspects of IPC implementation are government led with strong leadership support, stable funding and sustainability planning are yet to be achieved and will be crucial for long-term success. Conclusions: Most aspects of the IPC core components have been well implemented at the national level since the establishment of the IPC program. However, the program should continue improving the scope and quality of implementation and focus on the development of long-term plans to sustain existing gains and further improve on gap areas at the national level and especially the healthcare-facility level.

Background: Hand hygiene (HH) remains arguably the most effective way to prevent healthcare-associated infections (HAIs) and ultimately improve the prospect of patient safety. Studies have shown that as many as 50%–70% of infections are transmitted through hands due to poor HH practices. HH with use of alcohol-based hand rub (ABHR) is preferred over handwashing with soap and water because of its wide microbial efficacy, time efficiency, and improved skin tolerance. It is also well known that ABHR can be used as an effective prevention measure during disease outbreaks. Before and during the COVID-19 pandemic, health facilities in Sierra Leone have been challenged with HH infrastructural problems such as lack of sinks with constant running water. Before Sierra Leone recorded its first case of COVID-19 in March 2020, the consumption of ABHR in the health facilities was estimated to be 24,000 L per year, which doubled during the COVID-19 pandemic. The demand for commercially available ABHR increased, leading to acute shortages. The estimated cost of the locally produced ABHR ~$2–3 per 500 mL, although it may cost up to $10 for 500 mL when buying imported ABHR products from the local market. Methods: All ingredients were procured locally, and ABHR production was based on WHO formula 1. The production was set for 12 months to cover the estimated annual consumption of ABHR, with periodic monitoring to ensure effective distribution and availability at the point of care. Analysis of assessment results in 12 hospitals from the pre-COVID-19 era (2019) to the COVID-19 era (2021) was performed based on the WHO IPC Assessment Framework (IPCAF) indicator. Results: With an average monthly production of 3,482 L, a total of 41,780 L ABHR was produced and packaged in branded 500-mL containers for distribution to healthcare facilities. This quantity exceeded the estimated demand for ABHR during the COVID-19 pandemic. The data show a considerable increase (from 25% to 44%) in the number of available and functioning HH stations with mainly locally produced ABHR. Results from the monitoring of 575 peripheral health units (PHUs) in 2021 also showed that >67% of PHUs had HH facilities in all clinical areas and that the locally produced ABHR was used in 79% of these HH stations. Conclusions: Locally produced ABHR has shown to be a cost-effective and evidence-based intervention to optimize HH at the point of care. Therefore, localities are encouraged to undertake this realistic and sustainable approach to address issues of acute shortage of ABHR, especially during a global pandemic.

Abstract Objective: Despite the impact of inappropriate prescribing on antibiotic resistance, data on surgical antibiotic prophylaxis in sub-Saharan Africa are limited. In this study, we evaluated antibiotic use and consumption in surgical prophylaxis in 4 hospitals located in 2 geographic regions of Sierra Leone. Methods: We used a prospective cohort design to collect data from surgical patients aged 18 years or older between February and October 2021. Data were analyzed using Stata version 16 software. Results: Of the 753 surgical patients, 439 (58.3%) were females, and 723 (96%) had received at least 1 dose of antibiotics. Only 410 (54.4%) patients had indications for surgical antibiotic prophylaxis consistent with local guidelines. Factors associated with preoperative antibiotic prophylaxis were the type of surgery, wound class, and consistency of surgical antibiotic prophylaxis with local guidelines. Postoperatively, type of surgery, wound class, and consistency of antibiotic use with local guidelines were important factors associated with antibiotic use. Of the 2,482 doses administered, 1,410 (56.8%) were given postoperatively. Preoperative and intraoperative antibiotic use was reported in 645 (26%) and 427 (17.2%) cases, respectively. The most commonly used antibiotic was ceftriaxone 949 (38.2%) with a consumption of 41.6 defined daily doses (DDD) per 100 bed days. Overall, antibiotic consumption was 117.9 DDD per 100 bed days. The Access antibiotics had 72.7 DDD per 100 bed days (61.7%). Conclusions: We report a high rate of antibiotic consumption for surgical prophylaxis, most of which was not based on local guidelines. To address this growing threat, urgent action is needed to reduce irrational antibiotic prescribing for surgical prophylaxis.